Integrated Community Care Delivered by Public Health-Care and Social-Care Systems: Results from a Realist Synthesis

Introduction: Integrated community care (ICC) is defined as an interweaving of health-care and social-care interventions deployed in spatial and relational proximity using an interdisciplinary and cross-sectoral approach. Consideration of territory scale and time scale are at the center of ICC practices. Its deployment in public health and social care networks (HSCN) can be complex due to their broad mandate, the complexity of their management, and accountability. Therefore, we aimed to describe ICC delivered by public HSCN to determine how, why, for whom, and in what circumstances ICC works and produces outcomes. Methods: A realist synthesis was conducted consisting of five steps consistent with realist synthesis standards (RAMESES projects) to produce configurations of Context – Mechanism – Outcomes (CMOc) and development of a middle-range explanatory theory of why and how the identified outcomes may have occurred. Results: In total, 26 studies were selected and used, as evidence, to support—either partially or fully—the production of CMOc based on the initial program theory. Nine unique CMO configurations were identified based on the data analyses and team discussion. ICC middle-range theory is informed by the CMO configurations identified. Discussion: This realist synthesis allowed us to identify the central mechanisms of ICC delivered by public HSCN and to produce a middle range theory. ICC is based on a specific philosophy and deployed by a professional agency oriented toward a community agency within a local system of interdisciplinary and cross-sectoral action. Conclusion: Our middle-range theory will provide a solid analytical framework as a foundation for ICC implementation and future research.


Data Coding Guide
(First version: December 2020 -Updated: May 2021) The design of this data coding guide is essentially inspired by the research question, its PICOs (Population/Intervention/Comparison/Outcome/setting) of the systematic review and the initial rough theories constituted in a form of CMO (Context-Mechanism-Effect) configurations for the realistic synthesis.
As more than two-thirds (2/3) of the writings are published in English, the data will be extracted directly in this language in order to reduce discordances related to the translation or interpretation of texts.
Given the complexity of community-based interventions in health and social care, the empirical data extracted are structured around criteria analysis divided as characteristics groups.These characteristics are declined in variables (or components) that are subject to be mutually inclusive and exhaustive modalities, each category taking into account with all the possible answers.Within a specific section, several modes associated with the same component may be selected simultaneously, in line with the multifaceted complexity of ICC.
The first section of the guide characterises the typology of the different publications (scientific studies and grey literature) used in the systematic review on ICC (community-based interventions deployed by the public health care and social care network, alone or in partnership).The sections on the intervention, its operation, contexts, mechanisms and outcomes specify the different components of the evidence extracted from the selected publications.
A data extraction grid has been designed to support the extraction process, particularly of contextual data (1st part of the codification guide, for the systematic review).The empirical statements of the CMO configurations are directly recorded in an additional tool to simplify the analysis of causal relations related to the evidence extracted from selected publications and considered as evidence (2nd part of the codification guide, for the realistic synthesis).
Within a realistic logic (realistic synthesis), the mechanism is at the heart of the intervention process.The mechanism is real, but hidden.It is underlying (happens in the heads of the actors) and therefore not directly observable.Indeed, the relevant mechanisms cannot be identified without reference to the outcomes just as important aspects of the context cannot be identified without reference to the mechanisms.Therefore, data related to mechanism will be at the heart of the extraction process and will ultimately provide elements to answer the research question: how, why, for whom, and in what contexts do ICCs deployed by the public health and social care work and produce outcomes?
The definition of the preliminary code structure is based on a deductive approach that integrates concepts already well known in the literature associated with integrated community care (ICC).

describe as indicated in the publication year
Year Year of publication.describe as indicated in the publication title Title Title of the publication.describe as indicated in the publication language Publication language Specify the language of publication of the full article.

PART 2 -DATA RELATED TO EMPIRICAL CONFIGURATIONS CONTEXT-MECHANISM-OUTCOME (CMOC) -FOR THE REALIST SYNTHESIS
CMO configurations statements outline the relationship between particular characteristics of contexts, mechanisms and effects in the following form: "In an 'X' context, the 'Y' mechanism generates the 'Z' effect".
As with the rough theories, the presentation of statements identified as potential empirical evidence distinguishes between CMO configurations that are intervention and management based.Furthermore, as they are extracted, the empirical data are analysed a posteriori to identify families of mechanisms in order to facilitate the identification of possible recurrences.

Empiricals specifics contexts (C)
The contextual elements identified and specific to a given intervention are directly extracted, if necessary the more general contextual elements (general context, challenges related to access, availability, continuity and quality of care, issues) and the elements related to the intervention (activities,intervention, management and governance strategies) previously recorded in the extraction grid are used to improve the analysis.

Empiricals identified or hidden mecanisms (M)
Human reasoning of the actors (ideas, choices and decisions) to how individual and collective change will be achieved and reaction of the actors (capacity to put their ideas, choices or decisions into practice) to the resources provided by the intervention produce effect in a given context.
Examples of potential mechanisms extracted from the raw theories that explain why and how the intervention works, from the practitioner's perspective: -Openness and willingness to understand the area of intervention, the actors present and its population.-Desire to share and exchange with other actors on the global vision of the characteristics and needs of the area and its population.-Interest in deploying a proximity approach (spatial and relational proximity).
-Base its action on a proximity approach -Support the individual empowerment of citizens -Supporting the strengthening of citizens' collective power to act -Intervene in proximity, in a flexible and adapted manner in synergy -Openness to the involvement of citizens/users and their relatives in decisions concerning their care and services.-valuing the contribution of the knowledge of all: practitioners, citizens/users and relatives -Openness to partnership approaches -Linking and dynamically adapting the practices and actions of the various actors involved in the same community -other

studies only.  before-and-after (BA) studies  cross-sectional study  focus group study  interview study  longitudinal studies  meta-analysis  non-participant observation  participant observation  pre-post study  survey  systematic review  not scienific publication other (specify)
implementing an intervention intervening in proximity managing an intervention other (specify) Section Characteristics of the actors of the intervention (BY WHOM: ACTORS) NGOs and community-based organisations (non-profit cooperatives....) civic entities (neighbourhood-Write nd if not declared.Section Characteristics of the target population (FOR WHOM: BACKGROUND)